Referrals - 2020 UnitedHealthcare Administrative Guide

The PCP is responsible for determining when the member needs a referral. Only the PCP may make an initial referral. These must be made to participating care providers. We deny claims for services rendered without a proper referral. You may not bill the member for those services unless, prior to receiving the service, the member agrees in writing:

  1. That the referral is not in place or the service is not a covered service, and
  2. To be financially responsible for the cost of the service.

Referrals to a specialist may be necessary:

  • When a member fails to respond to current medical treatment.
  • To confirm or establish a member’s diagnosis and/or treatment modality.
  • To provide diagnostic studies, treatments or procedures that range beyond the scope of the PCP. PCPs may make referrals to a specialist according to the Specialty Referral Guidelines section.

These specialty services do not require referral:

  • Chiropractic (subject to benefit limitations)
  • Dermatology (five visits per calendar year)
  • Gynecology
  • Podiatry*
  • Substance use treatment*
  • Mental health*

Out-of-Network Referrals

Out-of-network referrals are only approved when the services are not available from a participating care provider. Request out-of-network referrals by calling NHP at 877-842-3210. Once we receive the referral, the data will be reviewed and, if approved, entered into the system to help ensure payment of the specialist claims.

Specialty Referral Guidelines

  • Once the specialty services have been properly authorized, the member or PCP may schedule an appointment with the specialist.
  • Please submit specialist referrals online using referralLink.
  • We mail an authorization letter to the specialist for the member’s medical record.
  • We do not pay specialist claims without a referral.
  • The specialist should re-verify the member’s eligibility at the time of visit by calling Provider Services 877-842- 3210. Please refer to the back of the member’s health care ID card to help ensure the appropriate Provider Services department is contacted.

Call 800-817-4705 for behavioral health service requests.

All NHP HMO members require a referral before scheduling appointments for specialty services.

Obstetrics

A member may self-refer to an NHP obstetrician who is a participating care provider for routine obstetrical (OB) care. If the member is referred to a non-participating specialist, the specialist must notify us through UHCprovider.com or by calling 877-842-3210 to make sure accurate claims payment for ante- and postpartum care.

  • Plain film radiography performed by an NHP participating care provider or in the obstetrician’s office during an authorized visit, does not require prior authorization.
  • Routine labs performed in the obstetrician’s office, or that are provided by a participating care provider in support of an authorized visit, do not require prior authorization.
  • Office procedures and diagnostic and/or therapeutic testing performed in the obstetrician’s office that do not require prior authorization may be performed.

 

* See the prior authorization section of this supplement.